Migraine

400-800 mg at onset of migraine aura or headache - single-dose

10 mg/kg (max 400 mg) at onset in children 3 months to 11 years; 200-400 mg in adolescents >=12 years

Alternatives among the analgesics. NICE CG150 1.3.10 offers a triptan together with an NSAID or paracetamol; ibuprofen is the cheapest of the three and the most studied in migraine.

Ibuprofen 400 mg film-coated tablets (POM) SmPC section 4.2 (eMC product 7020)

NSAID used as first-line abortive therapy, taken as early as possible in an attack to blunt the pain and inflammatory component of migraine.

1 g at onset, repeated up to four times in 24 hours, maximum 4 g in 24 hours - single-dose, repeated within the attack

15 mg/kg/dose [child max 500 mg]

(15 mg/kg per dose, up to four times daily, maximum 60 mg/kg/day. CG150 covers people aged 12 and over; below that, treat as paediatric headache. Under 1 month: 10 mg/kg 3 or 4 times daily, maximum 40 mg/kg/day (MSF Essential Drugs 2024).)

MSF Essential Drugs 2024 - paracetamol (oral)

NICE CG150 puts paracetamol in acute migraine twice: 1.3.10 offers an oral triptan plus paracetamol as combination therapy, and 1.3.11 lists paracetamol among the monotherapy options. The Egyptian EML lists paracetamol under antimigraine medicines for treatment of the acute attack. The dose is the MSF drug reference's.

900 mg (three 300 mg tablets) as a single dose at onset of the attack - single-dose

Do not give aspirin to anyone under 16 years - Reye's syndrome. CG150 covers ages 12 and over, but for aspirin the paediatric prohibition takes precedence.

Egyptian National Drug Formulary - Cardiovascular 2024 (acetylsalicylic acid monograph), "Migraine, acute treatment ... IR Oral tablet: 900 mg or 1 g once", which also lists the 300 mg tablet strength, corroborated by Migraine Headache - StatPearls (NCBI Bookshelf NBK560787) - https://www.ncbi.nlm.nih.gov/books/NBK560787/: "Ibuprofen (400-600 mg), naproxen (275-825 mg), diclofenac (65 mg), aspirin (900-1000 mg), or acetaminophen (1000 mg)."

NICE CG150 1.3.11 names aspirin 900 mg as a monotherapy option for the acute treatment of migraine, with the dose written into the recommendation. The Egyptian EML lists acetylsalicylic acid 300 mg and 500 mg tablets under antimigraine medicines for the acute attack. It is cheap and it is everywhere in Egypt.

A single 50 mg tablet at onset; some patients may require 100 mg. If the first dose does not work, do NOT take a second for the same attack - treat that attack with paracetamol, aspirin or an NSAID instead. If it worked and the headache comes back, a second dose may be given after a minimum interval of 2 hours. No more than 300 mg in any 24 hours. - Per attack - the label says it must not be used prophylactically

Not for children on this label: efficacy and safety are not established under 10 years, and in 10 to 17 year olds the label says use is not recommended.

Sumatriptan 50mg Tablets SmPC sections 4.1-4.2 (eMC product 524)

5-HT1 receptor agonist (triptan) that constricts cranial vessels and dampens neurogenic inflammation in the trigeminovascular pathway; used for attacks not controlled by simple analgesics.

Migraine Headache - disease-level clinical article (migraine-clinical.txt)

Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen.

40 mg BID for prophylaxis, titrate to 80-160 mg daily - long-term

Specialist use for pediatric migraine prophylaxis

Alternatives. NICE CG150 1.3.18 names propranolol, amitriptyline and topiramate together; propranolol is the cheapest and topiramate must be avoided in a woman who could become pregnant.

Egyptian National Drug Formulary - Cardiovascular 2024 (propranolol monograph)

Non-selective beta-blocker used for migraine prophylaxis to reduce attack frequency, distinct from the abortive agents used once an attack has started.

10-25 mg once daily at bedtime for prophylaxis, titrate up to 50-75 mg - long-term

Specialist use for refractory pediatric migraine

Amitriptyline 25 mg Film-Coated Tablets SmPC section 4.2 (eMC product 13683)

Tricyclic antidepressant used at low dose for its effect on central pain-modulating pathways, an alternative prophylactic agent for reducing migraine frequency.

25 mg nightly for one week, increased by 25 mg/day at weekly intervals to 100 mg/day in two divided doses; up to 200 mg/day may be tolerated - long-term, withdrawn gradually by 25-50 mg a week

(Licensed for migraine prophylaxis from 12 years, using the adult titration. The formulary's paediatric mg/kg schedules are for epilepsy, not migraine, and cannot be applied here.)

Egyptian National Drug Formulary - Nervous System Disorders 2025 (topiramate monograph)

NICE CG150 1.3.18 puts topiramate alongside propranolol and amitriptyline as one of the three drugs to consider for migraine prevention, and the Egyptian formulary carries migraine prophylaxis from 12 years as a licensed indication with a full titration schedule. The entry currently offers only two of the three - which matters most for the asthmatic patient, where propranolol is contraindicated.

10 mg at onset, repeated up to three times daily; maximum 30 mg in 24 hours, maximum 5 days - within the attack, no more than 5 days

Not for migraine nausea in children. The Egyptian formulary's paediatric indications are post-operative and chemotherapy-induced nausea only, second line, from 1 year, and extrapyramidal reactions are commonest in children and young adults.

Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (metoclopramide monograph)

NICE CG150 1.3.13 says to consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting, and 1.3.14 names metoclopramide by name where oral preparations fail. The Egyptian formulary's own oral adult indication is 'symptomatic treatment of nausea and vomiting, including acute migraine-induced nausea and vomiting'. Nausea is what stops the triptan being absorbed - this is the row that makes the rest of the prescription work.